tpp monitoring program atlas 20 prescription drug

PRESCRIPTION DRUG MONITORING PROGRAM ATLASTPP 20

19A L B E R TA

Alberta’s prescription drug monitoring program, TPP Alberta, uses data to optimize safe patient care. Since it was established in 1986, TPP Alberta has been monitoring the use of certain medications prone to misuse.

The mandate of TPP Alberta is:

• Tomonitorprescribing,dispensingandutilizationpracticesregardingtargetedmedications;

• Toprovidetimelyandrelevantinformationontargetedmedicationstoprescribers,dispensers,consumers,regulatorybodiesandstakeholders;

• Toworkwithstakeholderstoenablesystemlevelchangetoensureappropriateuseoftargetedmedications;

• ToensureefficientandeffectivefunctioningofTPPAlberta.

FundedprimarilybytheprovinceofAlberta,TPPAlbertarepresentsapartnershipwithprogramadministrationbytheCollegeofPhysicians&SurgeonsofAlberta(CPSA).Thelistofpartnersincludes:

AlbertaCollegeofPharmacy

Alberta Dental Association and College

Alberta Health

AlbertaHealthServices

Alberta Medical Association

Alberta Pharmacists’ Association

AlbertaVeterinaryMedicalAssociation

College and Association of Registered Nurses of Alberta

CollegeofPhysicians&SurgeonsofAlberta

CollegeofPodiatricPhysiciansofAlberta

©CollegeofPhysicians&SurgeonsofAlberta,2020.

CopyingordistributionofthisdocumentisnotpermittedwithouttheexpresswrittenconsentoftheCollegeofPhysicians&SurgeonsofAlberta,administratorofTPPAlberta.

ThisworkwasproducedbyOKAKI™forTPPAlberta.

Suggested Citation:

EllehojE,McDermottC,EurichDT,GilaniF,SmilskiK,JessE,SamananiS.2019TPPAlbertaPrescriptionDrugMonitoringProgramAtlas.Edmonton,Alberta:TheCollegeofPhysicians&SurgeonsofAlberta;2020.62p.

Background and Methods ................................................................................ 2

Medication Use – Opioids ................................................................................ 6

Opioid by Main Ingredient....................................................................................... 7

Opioids by Dose and Number of Ingredients ......................................................... 8

Opioid Patients by Number of Prescribers .............................................................. 9

Opioid Prescribing Trends by Month ....................................................................... 9

Top Five Opioid Prescriptions by Prescriber Group ................................................ 10

Medication Use – Benzodiazepines.................................................................. 12

Benzodiazepines by Main Ingredient ....................................................................... 13

Benzodiazepines by Dose and Number of Ingredients ........................................... 14

Benzodiazepine Patients by Number of Prescribers ............................................... 15

Benzodiazepine Prescribing Trends by Month ........................................................ 15

Top Five Benzodiazepine Prescriptions by Prescriber Group .................................. 16

Medication Use – Benzodiazepines in Elderly Patients ................................... 18

Medication Use – Concurrent Opioids and Benzodiazepines .......................... 19

Trends ............................................................................................................... 20

Veterinarian Prescriptions ............................................................................... 23

Geographic Analyses – Opioids ....................................................................... 24

Geographic Analyses – Benzodiazepines ......................................................... 36

Geographic Analyses – Benzodiazepines in Elderly Patients .......................... 48

Geographic Analyses – Concurrent Opioids and BDZ/Z.................................. 56

Appendix A – Opioid Analytic Class, 2019 ..................................................... 60

Appendix B – Benzodiazepine Analytic Class, 2019 ....................................... 61

List of Tables and Figures ................................................................................ 62

Contents

2019 PRESCRIPTION DRUG MONITORING PROGRAM ATLAS2

About the Atlas

The purpose of the TPP Alberta Prescription Drug Monitoring Program Atlas is to provide an overview of provincial TPP Alberta medication utilization for the year 2019. As with the 2018 Atlas, provincial utilization will be summarized for two classes of medications: opioids (including codeine-containing and tramadol-containing medications); and, benzodiazepines and benzodiazepine- type drugs (zopiclone and zolpidem). Tramadol was added to the TPP program in 2018 as a monitored drug. The source of information on medication utilization continues to be community pharmacy dispenses extracted from the Pharmaceutical Information Network (PIN), a part of Alberta’s electronic health record (Netcare). Data used in the Atlas analyses were extracted on June 10, 2020.

New additions to the 2019 Atlas are:

• an expanded exploration of consumption of benzodiazepines by patients 65 years and older,

• analyses of seasonal patterns for both opioids and benzodiazepine dispenses,

• an exploration of concurrent consumption of benzodiazepines and opioids,

• analyses of top five ingredients by prescriber type, including dispenses by Doctors of Veterinary Medicine (DVM),

• pharmacy local aggregated geographies are sorted on the graphs for each measure by observed rate of the specified measure, rather than by population,

• tramadol data from 2015 to 2019 were added to each year’s opioid measures; and,

• letter size format.

The addition of tramadol data for all five years results in higher OME level and count measures than last year’s Atlas, when only a few months of data related to this ingredient were included. Standardized age and sex population rates are used throughout the Atlas.

TPP Alberta Data Source

2019 PIN data were used for the analyses. On January 1, 2013, TPP Alberta officially switched from physical triplicate prescriptions to PIN as the primary data source for prescription monitoring. PIN data consist of dispense records from community pharmacies in Alberta. The primary source for methadone information switched from secure prescriptions to PIN data in August 2015, when it was found that virtually all methadone, which was previously prescribed and dispensed as a compound, switched to commercially available products with Drug Identification Numbers (DINs) captured in PIN. Ongoing gaps within PIN data include dispensing information from inpatient hospital pharmacies and affiliated facilities such as hospices. Also, compounded opioid medications and prescriptions for ‘office use’ are not reliably captured in PIN.

All prescriber types authorized to prescribe controlled drugs in Alberta and monitored via TPP Alberta are included in the analyses. In 2019, physicians prescribed 85.5% of all opioid dispenses (including codeine and tramadol) and 95.5% of all benzodiazepine dispenses (including z-drugs).

PIN data do not discriminate between medications actually dispensed from those awaiting release to the patient. As pharmacy records may be modified or reversed before the actual dispense, PIN data are dynamic. In an effort to capture actual dispensing as closely as possible, data for this 2019 Atlas were extracted from PIN on June 10, 2020, by which time most modifications and reversals would have occurred.

The data source for veterinarian prescriptions of controlled drugs for animals is the TPP Alberta Prescription Drug Monitoring program, as prescriptions for animal patients are not captured in PIN. Also, specific animal patient and dosage information are not available.

Veterinarian prescriptions for animals were not included in overall analyses, but are shown for the two analytic class sections.

Backgrounds and Methods

3

Pharmacy Local Aggregated Geography

Pharmacy local aggregated geographies (PhLAG) merge local geographies, used by Alberta Health and Alberta Health Services, with neighboring geographies where their residents are dispensed medications, eliminating previous issues with utilization rates in local geographies being artificially low or high. In this Atlas, drug utilization rates count patients in the numerator in each PhLAG where they received prescription dispenses.

The merging of geographies has primarily occurred in smaller cities such as Red Deer, Lethbridge, Medicine Hat, Grande Prairie, Fort McMurray, Spruce Grove, etc. The total number of geographic units has been reduced from 132 local geographies to 106 pharmacy local aggregated geographies. The methods used to develop PhLAGs are consistent with those used to develop other Alberta geographic aggregations used in the health system, like subzones. Rural PhLAG names include various municipality types, such as County, Planning and Special Area, and Municipal District.

Analytic Drug Class

Analyses of medication utilization were carried out by analytic drug classes, based on the main ingredient of interest within each drug. In the case where a drug had two ingredients of interest, one was chosen as the main ingredient. The two analytic drug classes included in the Atlas are opioids and benzodiazepines. Opioids consist of all opioids and some non-opioid drugs (with a potential for harm or diversion) currently requiring a secure prescription. Consistent with the 2015-2018 Atlases, codeine-containing medications which were dispensed from a regular prescription or available over the counter (8 mg codeine per solid dosage form and 20 mg/30 ml for liquid formulations) were included in the opioid analytic class. Benzodiazepines consist of all benzodiazepines and z-drugs currently monitored by TPP Alberta. Appendix A shows 2019 prescriptions for opioids by main ingredient and route of administration. Appendix B shows 2019 prescriptions for benzodiazepines by main ingredient and route of administration.

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Atlas Measures

TPP utilization is presented in this Atlas using population counts and rates. Age and sex standardized rates were calculated using 2019 Alberta PhLAG population estimates. Patient age was calculated at July 1, 2019.

Opioids

For the opioid analytic class, oral morphine equivalents (OME) were used as the standard measure of dose. Drug OME values were obtained primarily from the Centers for Disease Control1, the previous Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain² and the Compendium of Pharmaceuticals and Specialties³. The OME for compounds within the opioid class cannot be calculated as dose and/or route are unknown. Therefore, compounds do not contribute towards a patient’s total dose of opioids. Compounds are captured in all other quantity measures.

The OME for a specific drug dispense was calculated as follows:

Dispense OME = strength x quantity x drug OME

A patient’s total OME per day was calculated as follows:

Patient OME / day = the sum of the OME for all drug dispenses to the patient in the time period analyzed / days in the time period analyzed4

Population utilization of opioids was presented using the three measures below.

Opioid consumption = the sum of all patient OME / day in the time period analyzed / 1000 population

Opioid patients = the number of patients who received at least one opioid prescription in the time period analyzed / 1000 population

High dose opioid patients = the number of patients who received 90 OME / day or greater in the time period analyzed / 1000 population

The 2017 Canadian Guidelines for Opioids for Chronic Non-Cancer Pain set a watchful opioid dose of 50 OME/day5. This threshold is congruent with CDC Guidelines published in 20166.

5

Benzodiazepines

The benzodiazepine (BDZ/Z) analytic class includes benzodiazepines and benzodiazepine-like drugs (Z-drugs). The defined daily dose (DDD), as defined by the World Health Organization (WHO), is the assumed average daily maintenance dose for a drug used for its main indication in adults7. Drug DDD values were obtained primarily from the WHO DDD/ATC Index8. The number of DDDs (i.e., the dose in multiples of the DDD) was used as the standard measure of dosing across all drugs and routes of administration within the benzodiazepines (BDZ/Z) analytic class.

The DDD for compounds within the benzodiazepines class cannot be calculated as dose and/or route are unknown. Therefore, compounds do not contribute towards a patient’s total dose of benzodiazepines. Compounds are captured in all other quantity measures.

The DDDs for a specific drug dispense was calculated as follows:

Dispense DDDs = strength x quantity / drug DDD

A patient’s total DDDs was calculated as follows:

Patient DDDs = the sum of the DDDs for all drug dispenses to the patient in the time period analyzed / days in the time period analyzed4

Population utilization of BDZ/Z was presented using the five measures below. Population rates were age and sex standardized for comparison between pharmacy local aggregate geographies.

BDZ/Z consumption = the sum of all patient DDDs received in the time period analyzed / 1000 population

BDZ/Z patients = the number of patients who received at least one BDZ/Z prescription in the time period analyzed / 1000 population

High dose BDZ/Z patients = the number of patients who received 2 DDDs9 or greater in the time period analyzed / 1000 population

Elderly BDZ/Z patients = the number of patients 65 years and older who received at least one BDZ/Z prescription in the time period analyzed / 1000 elderly population

Concurrent Opioid BDZ/Z patients = patients who received both opioid and benzodiazepine prescriptions within the same quarter / 1000 population. Patients included were dispensed opioid and BDZ/Z prescriptions concurrently in one or more quarters.

1 National Center for Injury Prevention and Control. CDC compilation of benzodiazepines, muscle relaxants, stimulants, zolpidem, and opioid analgesics with oral morphine milligram equivalent conversion factors, 2016 version. Atlanta, GA: Centers for Disease Control and Prevention; 2016. Available at: https://www.cdc.gov/drugoverdose/resources/data.html

2 http://nationalpaincentre.mcmaster.ca/opioid/cgop_b_app_b08.html

3 https://www.e-therapeutics.ca/login.action?language=en

4 “Days in time period analyzed” is used because the “days of supply” information in the dispense record is often inaccurate within PIN data

5 2017 Canadian Guideline for Opioids for Chronic Pain. Available at: http://nationalpaincentre.mcmaster.ca/guidelines.html

6 Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1-49. DOI: https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1.pdf

7 Norwegian Institute of Public Health. WHOCC – Definition and General Considerations [Internet]. WHO Collaborating Centre for Drug Statistics Methodology. 2009 [cited 2014 Oct 7]. Available from: http://www.whocc.no/ddd/definition_and_general_considera/

8 http://www.whocc.no/atc_ddd_index/

9 For the purpose of this Atlas, 2 DDDs was used as the watchful dose of BDZ/Z

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Medication Use – Opioids

Table 1. Utilization of Prescription Opioids in Alberta, 2015-2019

Table 3. Opioid Prescriptions, Patients, and Prescribers by Prescriber Type, 2019

Prescriber Type Prescriptions Percent Patients Percent Prescribers PercentAll Prescribers 1,664,853 100.0 573,104 100.0 14,908 100.0

Physicians 1,422,891 85.5 471,734 82.3 10,687 71.7

Pharmacists 105,336 6.3 46,391 8.1 3,307 22.2

Dentists 101,468 6.1 86,472 15.1 494 3.3

Nurse Practitioners 22,387 1.3 8,774 1.5 417 2.8

Year Prescriptions Patients Prescribers Pharmacies PopulationOME per day per 1000 Population

Patientsper 1000Population

Patients ≥90 OME per 1000 Population

2015 1,941,252 628,762 13,767 1,544 4,196,192 1,667 149.8 3.7

2016 2,031,450 654,616 14,789 1,583 4,252,720 1,637 153.9 3.7

2017 1,934,117 634,301 15,330 1,387 4,285,997 1,431 148.0 3.2

2018 1,769,768 597,055 15,215 1,476 4,306,822 1,260 138.6 2.8

2019 1,664,853 573,104 14,908 1,533 4,371,154 1,195 131.1 2.6

5 year trend

Table 2. Opioid Patients by Age and Sex, 2019*

0-9 300 0.1 334 0.1 635 0.1

10-19 12,864 4.1 10,981 4.2 23,845 4.2

20-29 35,920 11.6 27,801 10.6 63,723 11.1

30-39 52,979 17.0 41,520 15.8 94,507 16.5

40-49 52,298 16.8 44,258 16.9 96,560 16.8

50-59 56,561 18.2 51,096 19.5 107,663 18.8

60-69 50,248 16.2 48,012 18.3 98,265 17.1

70-79 29,819 9.6 25,937 9.9 55,756 9.7

80-89 14,992 4.8 10,331 3.9 25,324 4.4

90+ 4,789 1.5 1,981 0.8 6,770 1.2

Total 310,794 100.0 262,279 100.0 573,104 100.0

*24 female patients of unknown age, 28 male patients of unknown age, 27 patients of unknown sex, and 4 patients of unknown sex or age.

Note: Prescriptions sum does not match the summary value because only the four major prescriber types are shown. Other known prescriber types are associated with 245 prescriptions (Opticians 127, Dental Hygienists 71, Dieticians 46, and Podiatrists 1).

Note: Patient sum does not match the summary values because patients may obtain prescriptions from more thanone prescriber type.

12,526 prescriptions have no prescriber type identified. Also, there are instances where no specified prescriber is identified within the shown groups; i.e., 2% of prescriptions by physicians,1% by pharmacists, 96% by dentists and 5% by nurse practitioners have an unidentified prescriber.

Figure 1. Opioid Patients by Age and Sex, 2019

Females MalesAge

Group Females Percent Males Percent Total Patients Percent

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Main Ingredient 2015 2016 2017 2018 2019 2019 5 Year TrendCodeine 12,801 13,544 13,802 13,399 13,019

Tramadol 8,049 9,022 9,552 9,834 9,855

Hydromorphone 4,556 5,144 5,491 5,648 5,808

Oxycodone 5,425 5,941 5,933 5,997 5,691

Morphine 3,950 4,232 4,234 4,271 4,186

Buprenorphine 1,518 1,727 1,796 2,080 2,527

Fentanyl 2,126 2,181 2,057 1,943 1,985

Methadone 456 522 592 722 917

Butalbital 739 698 661 627 579

Tapentadol 619 574 517 470 467

Main Ingredient 2015 2016 2017 2018 2019 2019 5 Year TrendCodeine 495,352 503,477 474,206 427,986 398,171

Tramadol 110,869 127,838 137,718 143,417 145,161

Oxycodone 71,759 74,039 63,356 54,434 47,597

Hydromorphone 24,280 29,663 31,268 32,983 34,571

Morphine 16,263 16,464 15,273 14,525 13,681

Buprenorphine 5,587 6,673 7,759 9,583 11,546

Methadone 5,028 5,363 5,702 6,217 6,732

Fentanyl 5,164 4,743 4,350 3,980 3,702

Butalbital 992 908 831 753 684

Tapentadol 1,278 1,001 886 806 684

Table 5. Opioid Patients by Main Ingredient, 2015-2019*

Table 6. Opioid Prescribers by Main Ingredient, 2015-2019(

Table 4. Opioid Prescriptions by Main Ingredient, 2015-2019*

Main Ingredient 2015 2016 2017 2018 2019 2019 5 Year TrendCodeine 1,195,184 1,202,623 1,099,300 939,960 851,198

Tramadol 188,202 216,673 231,857 242,397 237,325

Oxycodone 286,201 302,925 273,848 241,005 209,151

Hydromorphone 100,255 120,623 123,096 117,637 118,525

Buprenorphine 23,375 36,762 54,389 72,829 88,012

Methadone 48,194 53,289 60,568 69,832 77,000

Morphine 65,225 65,748 61,054 59,608 59,296

Fentanyl 22,115 21,505 19,823 17,471 16,419

Tapentadol 4,666 4,017 3,638 3,368 3,110

Butalbital 2,805 2,726 2,491 2,273 2,123

* The ten most commonly prescribed ingredients are displayed. See Appendix A for details on less commonly prescribed ingredients.


Patients

Associated Prescribers

Table 7. Opioid Patients and Associated Prescribers by Dose, 2015-2019

Patient Dose* 2015 2016 2017 2018 2019 2019 5 Year TrendTotal Patients 628,762 654,616 634,301 597,055 573,104

≥ 50 OME/day 25,432 26,077 23,648 21,434 20,047

≥ 90 OME/day 15,305 15,519 13,763 11,953 11,170

≥ 200 OME/day 7,134 7,038 5,947 5,031 4,761

≥ 400 OME/day 2,822 2,694 2,221 1,809 1,842

≥ 600 OME/day 1,433 1,360 1,063 897 914

≥ 800 OME/day 827 761 582 500 527

≥ 1,000 OME/day 532 490 377 321 348

≥ 2,000 OME/day 80 57 52 32 56

Patient Dose* 2015 2016 2017 2018 2019 2019 5 Year TrendTotal Prescribers 13,767 14,789 15,330 15,215 14,908

≥ 50 OME/day 7,871 8,251 7,890 6,999 6,726

≥ 90 OME/day 6,469 6,745 6,246 5,338 5,085

≥ 200 OME/day 4,427 4,517 3,914 3,346 3,061

≥ 400 OME/day 2,498 2,421 1,940 1,552 1,475

≥ 600 OME/day 1,509 1,455 1,070 862 826

≥ 800 OME/day 903 842 630 528 524

≥ 1,000 OME/day 586 562 407 376 369

≥ 2,000 OME/day 96 71 73 52 75

Note: Of 573,104 patients who received opioids in 2019, 553,057 (96.5%) received < 50 OME/day.

* can include prescriptions from multiple prescribersNote: Of 14,908 prescribers in 2019, 8,182 (54.9%) prescribed < 50 OME/day.

9

Table 8. Opioid Patients by Number of Ingredients, 2015-2019

Table 9. Opioid Patients by Number of Prescribers, 2015-2019

Ingredients 2015 2016 2017 2018 2019 2019 5 Year Trend Total Patients 628,762 654,616 634,301 597,055 573,104

1 Ingredient 538,447 557,578 543,387 513,609 496,565

2 Ingredients 74,201 80,112 75,941 70,385 64,895

3 Ingredients 13,328 14,127 12,626 11,007 9,769

4 Ingredients 2,304 2,315 2,004 1754 1,574

5 Ingredients 421 407 297 262 267

6+ Ingredients 61 77 46 38 3

Prescribers 2015 2016 2017 2018 2019 2019 5 Year Trend Total Patients 628,762 654,616 634,301 597,055 573,104

1 Prescriber 437,619 454,276 448,545 434,911 424,281

2 Prescribers 107,745 114,740 109,861 100,905 93,912

3 Prescribers 39,281 41,720 38,954 33,467 30,556

4 Prescribers 17,964 18,685 17,222 14,008 12,444

5 Prescribers 9,686 9,877 8,505 6,388 5,647

6 Prescribers 5,646 5,723 4,522 3,317 2,803

7 Prescribers 3,611 3,345 2,583 1,772 1,504

8+ Prescribers 7,210 6,250 4,109 2,287 1,957

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Figure 2. Opioid Prescribing Trends by Month for Patients 0-64 Years, 2015-2019

Figure 3. Opioid Prescribing Trends by Month for Patients 65 Years and Older, 2015-2019

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Figure 4. Opioid Prescriptions by Ingredient for Physician Prescribers, 2019

Figure 5. Opioid Prescriptions by Ingredient for Pharmacist Prescribers, 2019

Main Ingredient Prescriptions %Codeine 648,803 46

Tramadol 218,859 15

Oxycodone 204,412 14

Hydromorphone 113,310 8

Buprenorphine 84,516 6

Other Ingredients 152,991 11


Tramadol 6,225 6

Methadone Hydrochloride 44 <1

Buprenorphine 7 <1

Oxycodone 7 <1

Other Ingredients 13 <1

Note: Black bar shows the proportion of physician opioid prescriptions relative to total opioid prescriptions by all prescriber types. See Table 3.

Note: Black bar shows the proportion of pharmacist opioid prescriptions relative to total opioid prescriptions by all prescriber types. See Table 3.

Note: The % column represents the number of prescriptions for each main ingredient as a proportion of all opioids prescribed by physicians.

Note: The % column represents the number of prescriptions for each main ingredient as a proportion of all opioids prescribed by pharmacists.

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Figure 6. Opioid Prescriptions by Ingredient for Dentist Prescribers, 2019

Figure 7. Opioid Prescriptions by Ingredient for Nurse Practitioner Prescribers, 2019


Tramadol 8,693 9

Oxycodone 1,564 2

Morphine 464 <1

Hydromorphone 142 <1



Hydromorphone 4,047 18

Buprenorphine 2,922 13

Methadone Hydrochloride 2,804 13

Morphine 2,702 12


Note: Black bar shows the proportion of dentist opioid prescriptions relative to total opioid prescriptions by all prescriber types. See Table 3.

Note: Black bar shows the proportion of nurse practitioner opioid prescriptions relative to total opioid prescriptions by all prescriber types. See Table 3.

Note: The % column represents the number of prescriptions for each main ingredient as a proportion of all opioids prescribed by dentists.

Note: The % column represents the number of prescriptions for each main ingredient as a proportion of all opioids prescribed by nurse practitioners.


Medication Use – Benzodiazepines

Table 10. Utilization of Prescription Benzodiazepines in Alberta, 2015-2019

Table 12. Benzodiazepine Prescriptions, Patients, and Prescribers by Prescriber Type, 2019

Year Prescriptions Patients Prescribers PharmaciesDDDs per 1000 Population

Patientsper 1000Population

Patients ≥ 2 DDDs

Patients ≥ 2 DDDs per 1000 Population

2015 1,220,487 373,641 12,033 1,345 41.6 89.0 15,186 3.6

2016 1,284,642 386,883 12,738 1,418 41.0 91.0 14,728 3.5

2017 1,204,418 369,828 13,151 1,385 36.6 86.3 12,257 2.9

2018 1,127,665 355,901 13,399 1,468 33.6 82.6 10,773 2.5

2019 1,057,581 343,277 13,379 1,530 30.8 78.5 9,825 2.2

5 year trend

Table 11. Benzodiazepine Patients by Age and Sex, 2019*

Note: Prescriptions sum does not match the summary value because only the four major prescriber types are shown. 104 prescriptions are associated with other known prescriber types (Opticians 78, Dieticians 17, Dental Hygienists 9).

Note: Patient sum does not match the summary values because patients may obtain prescriptions from more than one prescriber type.

5,879 prescriptions have no prescriber type identified. Also, no specific prescriber is identified within the four major prescriber types, i.e., 1% of prescriptions by physicians, < 1% by pharmacists, 96% by dentists and 7% by nurse practitioner have no identified prescriber.

Figure 8. Benzodiazepine Patients by Age and Sex, 2019

Females Males 0-9 405 0.2 542 0.4 947 0.3

10-19 3,971 1.8 2,292 1.8 6,263 1.8

20-29 18,458 8.5 9,395 7.4 27,853 8.1

30-39 29,977 13.9 17,565 13.8 47,542 13.8

40-49 33,099 15.3 20,160 15.9 53,259 15.5

50-59 41,883 19.4 25,253 19.9 67,136 19.6

60-69 41,434 19.2 25,780 20.3 67,214 19.6

70-79 27,449 12.7 16,386 12.9 43,835 12.8

80-89 14,817 6.9 8,091 6.4 22,908 6.7

90+ 4,597 2.1 1,693 1.3 6,290 1.8

Total 216,094 100.0 127,166 100.0 343,277 100.0

*4 female patients of unknown age, 9 male patients of unknown age, 15 patients of known age and unknown sex, 2 patients of unkown age or sex

AgeGroup Females Percent Males Percent Total

Patients Percent

Prescriber Type Prescriptions Percent Patients Percent Prescribers PercentAll Prescribers 1,057,581 100.0 343,277 100.0 13,379 100.0

Physicians 1,009,927 95.5 333,836 97.2 9,897 74.0

Pharmacists 25,121 2.4 15,296 4.5 3,006 22.5


Dentists 7,494 0.7 6,071 1.8 111 0.8

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BDZ/Z

Main Ingredient 2015 2016 2017 2018 2019 2019 5 Year TrendZopiclone 186,615 192,225 180,564 169,657 158,763

Lorazepam 143,231 151,540 144,670 141,627 139,704

Clonazepam 52,250 53,687 50,209 47,838 45,699

Zolpidem 16,671 17,645 17,475 17,102 16,893

Temazepam 25,427 24,094 19,555 16,475 14,130

Diazepam 15,188 15,965 14,097 12,785 12,350

Alprazolam 10,115 10,066 9,119 8,281 7,578

Clobazam 3,233 3,400 3,380 3,473 3,534

Triazolam 3,037 3,400 3,136 3,149 3,290

Bromazepam 4,351 4,147 3,254 2,703 2,311

Table 14. Benzodiazepine Patients by Main Ingredient, 2015-2019*


Lorazepam 7,643 8,128 8,369 8,579 8,596

Clonazepam 5,687 5,984 6,157 6,255 6,226

Diazepam 3,766 4,074 4,093 4,060 4,078

Zolpidem 3,389 3,774 3,905 4,021 4,053

Temazepam 3,809 3,949 3,888 3,659 3,501

Alprazolam 3,118 3,265 3,240 3,198 3,093

Clobazam 1,858 1,997 2,122 2,199 2,217

Bromazepam 1,596 1,639 1,530 1,418 1,294

Oxazepam 1,508 1,501 1,340 1,228 1,143

Table 15. Benzodiazepine Prescribers by Main Ingredient, 2015-2019*

Table 13. Benzodiazepine Prescriptions by Main Ingredient, 2015-2019*


Lorazepam 308,569 330,213 308,315 293,838 283,773

Clonazepam 164,802 172,169 169,395 158,148 148,888

Temazepam 91,799 86,440 68,682 57,666 49,591

Zolpidem 35,035 40,274 42,116 42,270 42,024

Diazepam 43,253 48,233 40,843 36,412 34,668

Alprazolam 28,436 28,938 26,771 25,014 22,826

Bromazepam 22,357 21,875 16,669 13,177 11,013

Clobazam 8,890 10,110 10,068 10,008 10,064

Nitrazepam 16,321 18,065 14,809 13,430 8,700

* The ten most commonly prescribed ingredients are displayed. See Appendix B for details on less commonly prescribed ingredients.


Table 16. Benzodiazepine Patients and Associated Prescribers by Dose, 2015-2019Patients


Patient Dose* 2015 2016 2017 2018 2019 2019 5 Year Trend Total Patients 373,641 386,883 369,828 355,901 343,277

≥ 1 DDDs 56,118 55,947 49,865 46,060 42,849

≥ 2 DDDs 15,186 14,728 12,257 10,773 9,825

≥ 4 DDDs 2,097 1,862 1,329 1,106 973

≥ 6 DDDs 515 449 301 227 225

≥ 8 DDDs 152 122 75 68 61

≥ 10 DDDs 63 49 34 28 24

Patient Dose* 2015 2016 2017 2018 2019 2019 5 Year Trend Total Prescribers 12,033 12,738 13,151 13,399 13,379

≥ 1 DDDs 8,447 8,888 8,895 8,999 8,833

≥ 2 DDDs 5,697 5,929 5,615 5,468 5,212

≥ 4 DDDs 2,252 2,127 1,557 1,298 1,136

≥ 6 DDDs 832 752 434 321 292

≥ 8 DDDs 325 266 85 89 76

≥ 10 DDDs 128 134 37 39 36

* can include prescriptions from multiple prescribers

15

BDZ/Z

Table 17. Benzodiazepine Patients by Number of Ingredients, 2015-2019

Table 18. Benzodiazepine Patients by Number of Prescribers, 2015-2019

Ingredients 2015 2016 2017 2018 2019 2019 5 Year Trend Total Patients 373,641 386,883 369,828 355,901 343,277

1 Ingredient 295,868 306,614 299,555 292,646 285,270

2 Ingredients 63,237 65,218 58,832 53,746 49,704

3 Ingredients 11,762 12,197 9,657 8,127 7,147

4 Ingredients 2,224 2,302 1,510 1,176 990

5 Ingredients 434 433 224 169 139

6+ Ingredients 116 119 50 37 27

Prescribers 2015 2016 2017 2018 2019 2019 5 Year Trend Total Patients 373,641 386,883 369,828 355,901 343,277

1 Prescriber 266,197 273,803 267,412 261,137 255,136

2 Prescribers 70,442 73,489 68,528 64,586 60,513

3 Prescribers 22,249 23,714 21,256 19,360 17,866

4 Prescribers 8,160 8,723 7,349 6,444 5,898

5 Prescribers 3,186 3,654 2,881 2,468 2,169

6 Prescribers 1,504 1,595 1,178 950 833

7 Prescribers 726 815 583 404 387

8+ Prescribers 1177 1090 641 552 475

50,000

40,000

30,000

20,000

10,000

0

Janu

ary

Sept

emb

er

May

Mar

ch

Nov

emb

er

July

Febr

uary

Oct

ob

er

Jun

e

Apr

il

Dec

emb

er

Aug

ust

Figure 9. Benzodiazepine Prescribing Trends by Month for Patients 0-64 Years, 2015-2019

Figure 10. Benzodiazepine Prescribing Trends by Month for Patients 65 Years and Older, 2015-2019

120,000

100,000

80,000

60,000

40,000

20,000

0

Janu

ary

Sept

emb

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May

Mar

ch

Nov

emb

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July

Febr

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Oct

ob

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Jun

e

Apr

il

Dec

emb

er

Aug

ust

Benzodiazepines 2019 Benzodiazepines 2015-2018 Average

Pres

crip

tions

Pres

crip

tions


Figure 11. BDZ/Z Prescriptions by Ingredient for Physician Prescribers, 2019

Figure 12. BDZ/Z Prescriptions by Ingredient for Pharmacist Prescribers, 2019

Main Ingredient Prescriptions %Zopiclone 400,382 40

Lorazepam 275,760 27

Clonazepam 146,994 15

Temazepam 48,796 5

Zolpidem 41,429 4



Zolpidem 128 1

Lorazepam 73 <1

Clobazam 41 <1

Clonazepam 41 <1


Note: Black bar shows the proportion of physician BDZ/Z prescriptions relative to total BDZ/Z prescriptions by all prescriber types. See Table 12.

Note: Black bar shows the proportion of pharmacist BDZ/Z prescriptions relative to total BDZ/Z prescriptions by all prescriber types. See Table 12.

Note: The % column represents the number of prescriptions for each main ingredient as a proportion of all BDZ/Z prescribed by physicians.

Note: The % column represents the number of prescriptions for each main ingredient as a proportion of all BDZ/Z prescribed by pharmacists.

17

BDZ/Z

Figure 13. BDZ/Z Prescriptions by Ingredient for Dentist Prescribers, 2019

Figure 14. BDZ/Z Prescriptions by Ingredient for Nurse Practitioner Prescribers, 2019

Main Ingredient Prescriptions %Lorazepam 3,751 50

Triazolam 2,820 38

Diazepam 615 8

Midazolam 96 1

Clonazepam 74 1

Other Ingredients 138 2


Lorazepam 2,607 29

Clonazepam 1,032 11

Temazepam 571 6

Diazepam 477 5

Other Ingredients 838 9

Note: Black bar shows the proportion of dentist BDZ/Z prescriptions relative to total BDZ/Z prescriptions by all prescriber types. See Table 12.

Note: Black bar shows the proportion of nurse practitioner BDZ/Z prescriptions relative to total BDZ/Z prescriptions by all prescriber types. See Table 12.

Note: The % column represents the number of prescriptions for each main ingredient as a proportion of all BDZ/Z prescribed by dentists.

Note: The % column represents the number of prescriptions for each main ingredient as a proportion of all BDZ/Z prescribed by nurse practitioners.


Medication Use – Benzodiazepines in Elderly Patients

Table 19. Utilization of Prescription Benzodiazepines in Elderly Patients in Alberta, 2015-2019

Year Prescriptions Patients Prescribers Pharmacies ElderlyPopulation

Elderly Patient DDDs

Elderly Patients DDDs per 1000 Population

Elderly Patients per 1000 Elderly Population

2015 324,499 105,647 8,453 1,283 487,055 60,388.5 124.0 216.9

2016 340,906 108,853 9,017 1,363 506,800 61,187.0 120.7 214.8

2017 337,198 107,083 9,397 1,353 529,962 57,205.7 107.9 202.1

2018 328,443 105,575 9,675 1,432 551,546 54,560.2 98.9 191.4

2019 317,583 103,725 9,696 1,490 580,391 52,697.9 90.8 178.7

5 year trend

Table 20. Elderly Benzodiazepine Patients, Prescriptions and Prescribers by Prescriber Type, 2019

Table 21. Elderly Benzodiazepine Patients and Associated Prescribers by Dose, 2015-2019

Elderly Patients


Patient Dose* 2015 2016 2017 2018 2019 2019 5 Year Trend Total Patients 105,647 108,853 107,083 105,575 103,725

≥ 1 DDDs 20,276 20,285 18,570 17,639 16,891

≥ 2 DDDs 3,939 3,853 3,296 2,956 2,856

≥ 4 DDDs 302 288 182 173 179

≥ 6 DDDs 58 49 33 23 37

≥ 8 DDDs 15 10 6 7 10

Patient Dose* 2015 2016 2017 2018 2019 2019 5 Year Trend Total Prescribers 8,453 9,017 9,397 9,675 9,696

≥ 1 DDDs 5,634 5,989 5,947 6,060 6,034

≥ 2 DDDs 2,857 2,961 2,705 2,559 2,455

≥ 4 DDDs 472 456 290 262 257

≥ 6 DDDs 109 84 49 38 62

≥ 8 DDDs 25 15 9 13 16

* can include prescriptions from multiple prescribers

Note: Prescriptions sum does not match the summary value because only the four major prescriber types are shown. Note: Patient sum does not match the summary values because patients may obtain prescriptions from more than one prescriber type.

Prescriber Type Prescriptions Percent Patients Percent Prescribers PercentAll Prescribers 317,583 100.0 103,725 100.0 9,696 100.0

Physicians 303,300 95.5 102,169 98.5 7,252 74.8

Pharmacists 9,893 3.1 6,439 6.2 2,206 22.8


Dentists 798 0.3 631 0.6 11 0.1

19

Medication Use – Concurrent Opioids and BDZ/ZBD

Z/Z IN ELD

ERLY PATIENTS // CO

NCU

RRENT O

PIOID

S & BD

Z/Z

Prescriber Type 2015 2016 2017 2018 2019 2019 5 Year TrendPhysicians 129,599 133,151 121,980 110,254 101,543

Pharmacists 31,071 30,433 26,514 19,426 15,835

Dentists 12,336 12,926 11,850 10,982 10,133

Nurse Practitioners 1,782 2,625 2,931 3,212 3,499

Table 22. Utilization of Concurrent Prescription Opioids and Benzodiazepines in Alberta, 2015-2019

Year PatientsPatients per 1000 population

Patients ≥ 90 OMEs and ≥ 2 DDDs

Elderly Patients

Elderly Patients per 1000 Elderly Population

2015 131,185 31 64 37,234 76

2016 134,809 32 47 38,606 76

2017 123,585 29 27 37,252 70

2018 111,914 26 15 34,970 63

2019 103,226 24 15 33,439 58

5 year

Table 23. Concurrent Opioid and Benzodiazepine Patients by Age and Sex, 2019*

*2 female patients of unknown age, 4 male patients of unknown age, 6 patients of unknown sex, and 2 patients of unknown sex or age.

Figure 15. Concurrent Opioid and Benzodiazepine Patients by Age and Sex, 2019

Females Males

Table 24. Concurrent Opioid and Benzodiazepine Patients by Prescriber Type in Alberta, 2015-2019

0-9 14 0.0 9 0.0 23 0.0

10-19 490 0.8 290 0.7 780 0.8

20-29 3,379 5.3 1,848 4.7 5,227 5.1

30-39 7,591 11.8 4,277 11.0 11,868 11.5

40-49 10,257 16.0 5,827 15.0 16,084 15.6

50-59 14,077 21.9 8,952 23.0 23,029 22.3

60-69 13,841 21.5 9,371 24.1 23,212 22.5

70-79 8,666 13.5 5,471 14.1 14,137 13.7

80-89 4,511 7.0 2,407 6.2 6,918 6.7

90+ 1,457 2.3 478 1.2 1,935 1.9

Total 64,285 100.0 38,934 100.0 103,226 100.0

Age Group Females Percent Males Percent Total

Patients Percent

Note: Concurrent Opioid BDZ/Z patients are patients who received both opioid and benzodiazepine prescriptions within the same quarter. Patients included were dispensed opioid and BDZ/Z prescriptions concurrently in one or more quarters.


Trends

Figure 17. Five Year Total OME per Day Trends for the Top Five PhLAGs in 2019

6,000

5,500

5,000

4,500

4,000

3,500

3,000

2,500

2,000

1,500

1,0002015 2016 2017 2018 2019

Tota

l OM

E pe

r 1,0

00 P

opul

atio

n

Year

Calgary – Centre

Starland County/Drumheller

Vegreville/Minburn County

Edmonton – Eastwood

Edmonton – Abbottsfield

Figure 16. Five Year Opioid Patient Trends for the Top Five PhLAGs in 2019

500

450

400

350

300

250

2002015 2016 2017 2018 2019

Patie

nts

per 1

,000

Pop

ulat

ion

Year

Cardston – Kainai



Frog Lake

Wabasca

Figure 18. Five Year Opioid Patients who Received 90 OME or Greater per Day Trends for the Top Five PhLAGs in 2019

13

12

11

10

9

8

7

6

52015 2016 2017 2018 2019

Patie

nts ≥

90

OM

E pe

r 1,0

00 P

opul

atio

n

Year

Crowsnest Pass

Pincher Creek

Starland County/Drumheller



21

TREND

S

Figure 19. Five Year Benzodiazepine Patient Trends for the Top Five PhLAGs in 2019

270

250

230

210

190

170

150

130

1102015 2016 2017 2018 2019

Patie

nts

per 1

,000

Pop

ulat

ion

Year

Crowsnest Pass

Sylvan Lake

Ponoka



Figure 20. Five Year Benzodiazepine DDDs Trends for the Top Five PhLAGs in 2019

130

120

110

100

90

80

70

60

502015 2016 2017 2018 2019To

tal D

DD

s pe

r 1,0

00 P

opul

atio

n

Year

Crowsnest Pass

Sylvan Lake

Ponoka


Barrhead

Figure 21. Five Year Benzodiazepine Patients Who Received 2 DDDs or Greater Trends for the Top Five PhLAGs in 2019

14

13

12

11

10

9

8

7

6

5

42015 2016 2017 2018 2019

Patie

nts ≥

2 D

DD

s per

1,0

00 P

opul

atio

n

Year

Ponoka

Viking



Barrhead


Figure 23. Five Year Total DDDs in Elderly Patients Trends for the Top Five PhLAGs in 2019

240

230

220

210

200

190

180

170

160

1502015 2016 2017 2018 2019

Tota

l DD

Ds

in E

lder

ly P

atie

nts

per

1,00

0 El

derly

Pop

ulat

ion

Year

Crowsnest Pass

Sylvan Lake

Viking

Barrhead

Boyle

Figure 24. Five Year Patients Who Consumed Opioids and Benzodiazepines in the Same Quarter Trends for the Top Five PhLAGs in 2019

230

210

190

170

150

130

110

90

70

502015 2016 2017 2018 2019Co

ncur

rent

Ben

zodi

azep

ine

and

Opi

oid

Patie

nts

per 1

,000

Pop

ulat

ion

Year

Cardston – Kainai



Wabasca

High Prairie

Figure 22. Five Year Elderly Benzodiazepine Patient Trends for the Top Five PhLAGs in 2019

340

320

300

280

260

240

2202015 2016 2017 2018 2019

2015 2016 2017 2018 2019

Elde

rly P

atie

nts

per

1,00

0 El

derly

Pop

ulat

ion

Year

Calgary – Centre

Planning & Special Area 2

Viking

Edmonton – Jasper Place & West

Edmonton – Barrhead

23

VETERINA

RIAN

PRESCRIPTION

S

Main Ingredient PrescriptionsTramadol 10,142

Buprenorphine 5,574

Hydrocodone 3,726

Codeine 1,395

Butorphanol 519

Other ingredients 526

Figure 25. Opioid Prescriptions by Ingredient for Veterinarian Prescribers, 2019

Note: Prescriptions by Veterinarians were created for animal clients, and not included in the analyses of opioid utilization

Figure 26. Benzodiazepine Prescriptions by Ingredient for Veterinarian Prescribers, 2019

Main Ingredient PrescriptionsAlprazolam 928

Diazepam 835

Clorazepate Dipotassium 62

Lorazepam 40

Midazolam 38

Other ingredients 24

Note: Prescriptions by Veterinarians were created for animal clients, and not included in the overall analyses of BDZ/Z utilization

Veterinarian prescriptions for animal clients are monitored by TPP Alberta, as there is a potential for misuse by the human owners of the animal patients. Veterinarian prescriptions for animals were not included in the overall analyses.

In 2019, 1,001 veterinarians in Alberta prescribed 21,882 opioid prescriptions for animal clients. 491 veterinarians prescribed 1,927 BDZ/Z prescriptions for animal clients.

The five most commonly prescribed ingredients are shown for the two analytic classes.

The data source for veterinarian prescriptions of controlled drugs for animals is the TPP Alberta Prescription Drug Monitoring program, as prescriptions for animal patients are not captured in PIN. Also, specific animal patient and dosage information are not available.

Veterinarian Prescriptions

24

Figure 27a. Age and Sex Standardized, Total OME per Day per 1,000 Population, by Pharmacy Local Aggregated Geographies, 2019

Legend: Provincial and Urban Maps

Lowest (<598)

Low (598 to 956)

Average (957 to 1,434)

Above Average (1,435 to 1,792)

High (1,793 to 2,151)

Highest (>2,151)

Total OME per Day per 1,000 Population

Geographic Analyses - Opioids

25

Edm

onto

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OPIO

IDS


Phar

mac

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cal A

ggre

gate

d G

eogr

aphi

esFigure 27b. Age and Sex Standardized, Total OME per Day per 1,000 Population,

by Pharmacy Local Aggregated Geographies, 2019 2019 Population

Rate

Lowest (<598)

Low (598 to 956)

Average (957 to 1,434)


High (1,793 to 2,151)

Highest (>2,151)

Total OME per Day per 1,000 Population

27

Phar

mac

y Lo

cal A

ggre

gate

d G

eogr

aphi

es

2019 Population

Rate


OPIO

IDS

Mauve bar shows the 95% confidence limits Black line shows provincial rate. Blue dots show the population.

28

Figure 28a. Age and Sex Standardized, Opioid Patients per 1,000 Population, by Pharmacy Local Aggregated Geographies, 2019


Lowest (<65.6)

Low (65.6 to 104.8)

Average (104.9 to 157.3)

Above Average (157.4 to 196.7)

High (196.8 to 236.0)

Highest (>236.0)

Patients per 1,000 Population

29

Edm

onto

nC

alga

ry

OPIO

IDS


Phar

mac

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cal A

ggre

gate

d G

eogr

aphi

esFigure 28b. Age and Sex Standardized, Opioid Patients per 1,000 Population,


Rate

Lowest (<65.6)

Low (65.6 to 104.8)

Average (104.9 to 157.3)


High (196.8 to 236.0)

Highest (>236.0)


31

Phar

mac

y Lo

cal A

ggre

gate

d G

eogr

aphi

es

2019 Population

Rate

Lowest (<65.6)

Low (65.6 to 104.8)

Average (104.9 to 157.3)


High (196.8 to 236.0)

Highest (>236.0)


OPIO

IDS


32

Figure 29a. Age and Sex Standardized, Opioid Patients Who Received 90 OME or Greater per Day per 1,000 Population, by Pharmacy Local Aggregated Geographies, 2019


Lowest (<1.3)

Low (1.3 to 2.0)

Average (2.1 to 3.1)


High (3.9 to 4.6)

Highest (>4.6)

Patients ≥90 OME per Day per 1,000 Population

33

Edm

onto

nC

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ry

OPIO

IDS


Phar

mac

y Lo

cal A

ggre

gate

d G

eogr

aphi

es

2019 Population

Rate

Lowest (<1.3)

Low (1.3 to 2.0)



High (3.9 to 4.6)

Highest (>4.6)


Figure 29b. Age and Sex Standardized, Opioid Patients Who Received 90 OME or Greater per Day per 1,000 Population, by Pharmacy Local Aggregated Geographies, 2019

35

Phar

mac

y Lo

cal A

ggre

gate

d G

eogr

aphi

es

2019 Population

Rate

Lowest (<1.3)

Low (1.3 to 2.0)



High (3.9 to 4.6)

Highest (>4.6)


OPIO

IDS


36

Figure 30a. Age and Sex Standardized, Total DDDs per 1,000 Population, by Pharmacy Local Aggregated Geographies, 2019


Lowest (<15.4)

Low (15.4 to 24.6)


Above Average (37,1 to 46.2)

High (46.3 to 55.4)

Highest (>55.4)

Total DDDs per 1,000 Population

Geographic Analyses - Benzodiazepines

37

BDZ/Z

Edm

onto

nC

alga

ry


Phar

mac

y Lo

cal A

ggre

gate

d G

eogr

aphi

esFigure 30b. Age and Sex Standardized, Total DDDs per 1,000 Population,


Rate

Lowest (<15.4)

Low (15.4 to 24.6)



High (46.3 to 55.4)

Highest (>55.4)


39

BDZ/Z

Phar

mac

y Lo

cal A

ggre

gate

d G

eogr

aphi

es

2019 Population

Rate

Lowest (<15.4)

Low (15.4 to 24.6)



High (46.3 to 55.4)

Highest (>55.4)



40

Figure 31a. Age and Sex Standardized, Benzodiazepine Patients per 1,000 Population, by Pharmacy Local Aggregated Geographies, 2019


Lowest (<39.3)

Low (39.3 to 62.8)



High (117.9 to 141.3)

Highest (>141.3)


41

BDZ/Z

Edm

onto

nC

alga

ry


Phar

mac

y Lo

cal A

ggre

gate

d G

eogr

aphi

esFigure 31b. Age and Sex Standardized, Benzodiazepine Patients per 1,000 Population,


Rate

Lowest (<39.3)

Low (39.3 to 62.8)



High (117.9 to 141.3)

Highest (>141.3)


43

BDZ/Z

Phar

mac

y Lo

cal A

ggre

gate

d G

eogr

aphi

es

2019 Population

Rate

Lowest (<39.3)

Low (39.3 to 62.8)



High (117.9 to 141.3)

Highest (>141.3)



44

Figure 32a. Age and Sex Standardized, Benzodiazepine Patients Who Received 2 DDDs or Greater per 1,000 population, by Pharmacy Local Aggregated Geographies, 2019


Lowest (<1.1)

Low (1.1 to 1.8)



High (3.4 to 4.0)

Highest (>4.0)

Patients ≥2 DDDs per 1,000 Population

45

BDZ/Z

Edm

onto

nC

alga

ry


Phar

mac

y Lo

cal A

ggre

gate

d G

eogr

aphi

es

2019 Population

Rate

Figure 32b. Age and Sex Standardized, Benzodiazepine Patients Who Received 2 DDDs or Greater per 1,000 population, by Pharmacy Local Aggregated Geographies, 2019

Lowest (<1.1)

Low (1.1 to 1.8)



High (3.4 to 4.0)

Highest (>4.0)


47

BDZ/Z

Phar

mac

y Lo

cal A

ggre

gate

d G

eogr

aphi

es

2019 Population

Rate

Lowest (<1.1)

Low (1.1 to 1.8)



High (3.4 to 4.0)

Highest (>4.0)



48

Figure 33a. Benzodiazepine Patients 65 Years and Older per 1,000 Elderly Population, by Pharmacy Local Aggregated Geographies, 2019


Lowest (<89)

Low (89 to 143)

Average (144 to 214)

Above Average (215 to 268)

High (269 to 322)

Highest (322)

Elderly Patients per 1,000 Elderly Population

Geographic Analyses - Benzodiazepines in Elderly Patients

49

Edm

onto

nC

alga

ry

BDZ/Z IN

ELDERLY PATIEN

TS


Phar

mac

y Lo

cal A

ggre

gate

d G

eogr

aphi

es

2019 Elderly Population

Rate

Figure 33b. Benzodiazepine Patients 65 Years and Older per 1,000 Elderly Population, by Pharmacy Local Aggregated Geographies, 2019

Lowest (<89)

Low (89 to 143)



High (269 to 322)

Highest (322)


51

Phar

mac

y Lo

cal A

ggre

gate

d G

eogr

aphi

es


Rate

Lowest (<89)

Low (89 to 143)



High (269 to 322)

Highest (322)



BDZ/Z IN

ELDERLY PATIEN

TS

52

Figure 34a. Total DDDs in Benzodiazepine Patients 65 Years and Older per 1,000 Elderly Population, by Pharmacy Local Aggregate Geographies, 2019


Lowest (<45)

Low (45 to 73)

Average (74 to 109)


High (137 to163)

Highest (>163)

Total DDDs in Elderly Patients per 1,000 Elderly Population

53

Edm

onto

nC

alga

ry

BDZ/Z IN

ELDERLY PATIEN

TS


Phar

mac

y Lo

cal A

ggre

gate

d G

eogr

aphi

es


Rate

Figure 34b. Total DDDs in Benzodiazepine Patients 65 Years and Older per 1,000 Elderly Population, by Pharmacy Local Aggregate Geographies, 2019

Lowest (<45)

Low (45 to 73)

Average (74 to 109)


High (137 to163)

Highest (>163)


55

Lowest (<45)

Low (45 to 73)

Average (74 to 109)


High (137 to163)

Highest (>163)


Phar

mac

y Lo

cal A

ggre

gate

d G

eogr

aphi

es


Rate


BDZ/Z IN

ELDERLY PATIEN

TS

56

Figure 35a. Concurrent Benzodiazepine and Opioid Patients per 1,000 Population, by Pharmacy Local Aggregated Geographies, 2019


Lowest (<14.7)

Low (14.7 to 23.4)



High (44.1 to 52.7)

Highest (>52.7)


Geographic Analyses - Concurrent Opioids and BDZ/Z

57

CON

CURREN

T OPIO

ID &

BDZ/Z

Edm

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alga

ry


Phar

mac

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cal A

ggre

gate

d G

eogr

aphi

es

2019 Population

Rate

Figure 35b. Concurrent Benzodiazepine and Opioid Patients per 1,000 population, by Pharmacy Local Aggregated Geographies, 2019

Lowest (<14.7)

Low (14.7 to 23.4)



High (44.1 to 52.7)

Highest (>52.7)


59

Phar

mac

y Lo

cal A

ggre

gate

d G

eogr

aphi

es

2019 Population

Rate

Lowest (<14.7)

Low (14.7 to 23.4)



High (44.1 to 52.7)

Highest (>52.7)



CON

CURREN

T OPIO

ID &

BDZ/Z


Appendix A – Opioid Analytic Class, 2019

Table 25. Opioid Analytic Class Prescriptions, Patients, Prescribers and Pharmacies by Main Ingredient, ATC Code and Route of Administration, 2019

Main Ingredient ATC Code Description Route Prescriptions Patients Prescribers PharmaciesBuprenorphine N02AE01-BUPRENORPHINE Buccal 394 163 72 126

Buprenorphine N02AE01-BUPRENORPHINE Transdermal 10,679 3,321 1,489 931

Buprenorphine N07BC51-BUPRENORPHINE, COMBINATIONS Sublingual 61,635 6,395 1,020 987

Butalbital N02AA79-CODEINE, COMBINATIONS WITH PSYCHOLEPTICS Oral 1,971 644 540 444

Butalbital N02BA71-ACETYLSALICYLIC ACID, COMB WITH PSYCHOLEPTICS Oral 296 121 126 115

Butorphanol N02AF01-BUTORPHANOL Nasal 326 73 87 82

Codeine M03BB53-CHLORZOXAZONE, COMBINATIONS EXCL PSYCHOLEPTICS Oral 25 14 12 11

Codeine N02AA59-CODEINE, COMBINATIONS Oral 5,010 2,610 1,472 723

Codeine N02AJ06 Oral 713,549 303,536 12,639 1,454

Codeine N02AJ07 Oral 1,601 1,134 665 372

Codeine N02BE51-ACETAMINOPHEN, COMB EXCL PSYCHOLEPTICS Oral 6,208 3,246 1,425 648

Codeine R05DA04-CODEINE Intramuscular 15 6 6 5

Codeine R05DA04-CODEINE Oral 65,004 29,769 5,506 1,379

Codeine R05DA04-CODEINE Unknown 102 89 18 19

Codeine R05DA20-COMBINATIONS Oral 104,709 85,924 3,396 1,373

Codeine R05FA02-OPIUM DERIVATIVES AND EXPECTORANTS Oral 36,393 31,425 3,868 1,247

Fentanyl N01AH01-FENTANYL Intramuscular 1,614 1,064 300 139

Fentanyl N02AB03-FENTANYL Buccal 31 11 8 12

Fentanyl N02AB03-FENTANYL Transdermal 15,821 3,175 1,860 913

Fentanyl N02AB03-FENTANYL Unknown 36 16 8 2

Hydrocodone R05DA03-HYDROCODONE Oral 56 30 29 30

Hydrocodone R05DA20-COMBINATIONS Oral 523 372 229 241

Hydromorphone N02AA03-HYDROMORPHONE Intramuscular 4,395 2,279 764 233

Hydromorphone N02AA03-HYDROMORPHONE Oral 112,309 31,589 5,631 1,377

Hydromorphone N02AA03-HYDROMORPHONE Unknown 12 8 6 7

Ketamine N01AX03-KETAMINE Intramuscular 38 14 9 13

Ketamine N01AX03-KETAMINE Unknown 7 4 4 4

Meperidine N02AB02-PETHIDINE Intramuscular 406 98 90 84

Meperidine N02AB02-PETHIDINE Oral 1,573 461 383 372

Methadone N07BC02-METHADONE Oral 69,366 6,066 675 915

Methadone N07BC02-METHADONE Unknown 320 168 106 67

Morphine N02AA01-MORPHINE Intramuscular 2,234 1,192 604 215

Morphine N02AA01-MORPHINE Intravenous 14 10 10 6

Morphine N02AA01-MORPHINE Oral 56,916 13,509 4,188 1,300

Morphine N02AA01-MORPHINE Parenteral 123 90 61 11

Morphine N02AA01-MORPHINE Rectal 106 31 34 33

Morphine N02AA01-MORPHINE Unknown 47 38 17 12

Normethadone R05DA20-COMBINATIONS Oral 14 14 11 13

Opium N02AA02-OPIUM Rectal 260 172 166 123

Oxycodone N02AA05-OXYCODONE Oral 107,148 19,400 4,444 1,365

Oxycodone N02AA05-OXYCODONE Rectal 75 11 14 11

Oxycodone N02AA05-OXYCODONE Unknown 5 3 3 3

Oxycodone N02AA55-OXYCODONE, COMBINATIONS Oral 1,563 417 305 294

Oxycodone N02AJ17 Oral 130,912 39,292 5,208 1,414

Oxycodone N02AJ18 Oral 120 35 37 37

Pentazocine N02AD01-PENTAZOCINE Oral 175 39 47 45

Remifentanil N01AH06-REMIFENTANIL Intravenous 1 1 1 1

Sufentanil N01AH03-SUFENTANIL Intravenous 5 3 4 2

Tapentadol N02AX06-TAPENTADOL Oral 3,353 803 470 471

Tramadol N02AJ13 Oral 18,567 17,155 4,390 1,216

Tramadol N02AX02-TRAMADOL Oral 5,846 5,256 2,419 1,085

Tramadol N02AX02-TRAMADOL Unknown 4 4 4 4

”Unknown” route indicates that the medication format and route were not specified on the prescription.

61

Appendix B – Benzodiazepine Analytic Class, 2019

Main Ingredient ATC Code Description Route Prescriptions Patients Prescribers PharmaciesAlprazolam N05BA12-ALPRAZOLAM Oral 24,906 8,245 3,199 1,269

Alprazolam N05BA12-ALPRAZOLAM Unknown 1 1 1 1

Bromazepam N05BA08-BROMAZEPAM Oral 13,085 2,690 1,419 891

Chlordiazepoxide N05BA02-CHLORDIAZEPOXIDE Oral 2,365 1,149 747 588

Clobazam N05BA09-CLOBAZAM Oral 9,717 3,384 2,165 1,033

Clobazam N05BA09-CLOBAZAM Unknown 245 95 97 64

Clonazepam N03AE01-CLONAZEPAM Oral 157,270 47,570 6,250 1,436

Clonazepam N03AE01-CLONAZEPAM Unknown 136 52 47 37

Clorazepate Dipotassium N05BA05-CLORAZEPATE POTASSIUM Oral 204 71 84 73

Diazepam N05BA01-DIAZEPAM Intramuscular 27 15 13 15

Diazepam N05BA01-DIAZEPAM Oral 36,052 12,592 4,022 1,347

Diazepam N05BA01-DIAZEPAM Rectal 141 100 59 88

Diazepam N05BA01-DIAZEPAM Unknown 33 16 13 18

Flurazepam N05CD01-FLURAZEPAM Oral 869 309 283 278

Lorazepam N05BA06-LORAZEPAM Intramuscular 147 123 105 38

Lorazepam N05BA06-LORAZEPAM Oral 99,514 46,020 6,241 1,423

Lorazepam N05BA06-LORAZEPAM Sublingual 192,676 103,791 7,852 1,444

Lorazepam N05BA06-LORAZEPAM Unknown 40 29 25 12

Midazolam N05CD08-MIDAZOLAM Intramuscular 2,055 1,549 329 187

Midazolam N05CD08-MIDAZOLAM Unknown 56 41 14 12

Nitrazepam N05CD02-NITRAZEPAM Oral 13,366 2,466 1,091 782

Nitrazepam N05CD02-NITRAZEPAM Unknown 36 14 13 13

Oxazepam N05BA04-OXAZEPAM Oral 4,709 1,622 1,229 767

Temazepam N05CD07-TEMAZEPAM Oral 57,436 16,418 3,661 1,336

Temazepam N05CD07-TEMAZEPAM Unknown 28 10 10 9

Triazolam N05CD05-TRIAZOLAM Oral 4,875 3,125 636 822

Zaleplon N05CF03-ZALEPLON Oral 1 1 1 1

Zolpidem N05CF02-ZOLPIDEM Sublingual 42,113 17,040 4,024 1,279

Zopiclone N05CF01-ZOPICLONE Oral 459,678 168,871 11,337 1,454

Zopiclone N05CF01-ZOPICLONE Unknown 16 8 9 6

Table 26. Benzodiazepine Analytic Class Prescriptions, Patients, Prescribers and Pharmacies by Main Ingredient, ATC code and Route of Administration, 2019

”Unknown” route indicates that the medication format and route were not specified on the prescription.

APPEN

DIX


List of Tables and Figures

TablesTable 1. Utilization of Prescription Opioids in Alberta, 2015-2019 ...... 6

Table 2. Opioid Patients by Age and Sex, 2019*................................... 6

Table 3. Opioid Prescriptions, Patients, Prescribers by Prescriber Type, 2019.............................................................................. 6

Table 4. Opioid Prescriptions by Main Ingredient, 2015-2019* ........... 7

Table 5. Opioid Patients by Main Ingredient, 2015-2019*.................... 7

Table 6. Opioid Prescribers by Main Ingredient, 2015-2019* .............. 7

Table 7. Opioid Patients and Associated Prescribers by Dose, 2015-2019 ................................................................................................ 8

Table 8. Opioid Patients and Prescribers by Number of Ingredients, 2015-2019 ................................................................................................ 9

Table 9. Opioid Patients by Number of Prescribers, 2015-2019 .......... 9

Table 10. Utilization of Prescription Benzodiazepines in Alberta, 2015-2019 ...............................................................................................12

Table 11. Benzodiazepine Patients by Age and Sex, 2019* .................12

Table 12. Benzodiazepine Prescriptions, Patients, Prescribers and Pharmacies by Prescriber Type, 2019 ...................................................12

Table 13. Benzodiazepine Prescriptions by Main Ingredient, 2015-2019* ..............................................................................................13

Table 14. Benzodiazepine Patients by Main Ingredient, 2015-2019* ..............................................................................................13

Table 15. Benzodiazepine Prescribers by Main Ingredient, 2015-2019* ..............................................................................................13

Table 16. Benzodiazepine Patients and Associated Prescribers by Dose, 2015-2019 .....................................................................................14

Table 17. Benzodiazepine Patients and Prescribers by Number of Ingredients, 2015-2019 ..........................................................................15

Table 18. Benzodiazepine Patients by Number of Prescribers, 2015-2019 ...............................................................................................15

Table 19. Utilization of Prescription Benzodiazepines in Elderly Patients in Alberta, 2015-2019 ..............................................................18

Table 20. Elderly Benzodiazepine Patients, Prescriptions and Prescribers by Prescriber Type, 2019 ....................................................18

Table 21. Benzodiazepine Elderly Patients and Associated Prescribers by Dose, 2015-2019 ............................................................18

Table 22. Utilization of Concurrent Prescription Opioids and Benzodiazepines in Alberta, 2015-2019 ...............................................19

Table 23. Concurrent Opioid and Benzodiazepine Patients by Age and Sex, 2019* ................................................................................19

Table 24. Concurrent Opioid and Benzodiazepine Patients by Prescriber Type in Alberta, 2015-2019..................................................19

Table 25. Opioid Analytic Class Prescriptions, Patients, Prescribers and Pharmacies by Main Ingredient, ATC Code and Route of Administration, 2019 ...................................................... 60

Table 26. Benzodiazepine Analytic Class Prescriptions, Patients, Prescribers and Pharmacies by Main Ingredient, ATC code and Route of Administration, 2019...............................................................61

FiguresFigure 1. Opioid Patients by Age and Sex, 2019 ................................... 6

Figure 2. Opioid Prescriptions for Patients 0-64 Years, by Month, 2019 ........................................................................................ 9

Figure 3. Opioid Prescriptions for Patients 65 Years and Older, by Month, 2019 ........................................................................................ 9

Figure 4. Opioid Prescriptions by Ingredient for Physician Prescribers, 2019 ....................................................................................10

Figure 5. Opioid Prescriptions by Ingredient for Pharmacist Prescribers, 2019 ....................................................................................10

Figure 6. Opioid Prescriptions by Ingredient for Dentist Prescribers, 2019 ....................................................................................11

Figure 7. Opioid Prescriptions by Ingredient for Nurse Practitioner Prescribers, 2019 ....................................................................................11

Figure 8. Benzodiazepine Patients by Age and Sex, 2019 ...................12

Figure 9. Benzodiazepine Prescriptions for Patients 0-64 Years, by Month, 2019 .......................................................................................15

Figure 10. Benzodiazepine Prescriptions for Patients 65 Years and Older, by Month, 2019 ....................................................................15

Figure 11. BDZ/Z Prescriptions by Ingredient for Physician Prescribers, 2019 ....................................................................................16

Figure 12. BDZ/Z Prescriptions by Ingredient for Pharmacist Prescribers, 2019 ....................................................................................16

Figure 13. BDZ/Z Prescriptions by Ingredient for Dentist Prescribers, 2019 ....................................................................................17

Figure 14. BDZ/Z Prescriptions by Ingredient for Nurse Practitioner Prescribers, 2019 ...............................................................17

Figure 15. Concurrent Opioid and Benzodiazepine Patients by Age and Sex, 2019 ............................................................................19

Figure 16. Five Year Opioid Patient Trends for the Top Five PhLAGs in 2019 ..................................................................................... 20

Figure 17. Five Year Total OME per Day Trends for the Top Five PhLAGs in 2019 ..................................................................................... 20

Figure 18. Five Year Opioid Patients who Received 90 OME or Greater per Day Trends for the Top Five PhLAGs in 2019 .................. 20

Figure 19. Five Year Benzodiazepine Patient Trends for the Top Five PhLAGs in 2019 ...................................................................... 21

Figure 20. Five Year Bezodiazepine DDDs Trends for the Top Five PhLAGs in 2019 ...................................................................... 21

Figure 21. Five Year Benzodiazepine Patients Who Received 2 DDDs or Greater Trends for the Top Five PhLAGs in 2019 ............. 21

Figure 22. Five Year Elderly Benzodiazepine Patient Trends for the Top Five PhLAGs in 2019 .......................................................... 22

Figure 23. Five Year Total DDDs in Elderly Patients Trends for the Top Five PhLAGs in 2019 ................................................................ 22

Figure 24. Five Year Patients Who Consumed Opioids and Benzodiazepines in the Same Quarter Trends for the Top Five PhLAGs in 2019 ..................................................................................... 22

Figure 25. Opioid Prescriptions by Ingredient for Veterinarian Prescribers, 2019 ................................................................................... 23

Figure 26. Benzodiazepine Prescriptions by Ingredient for Veterinar-ian Prescribers, 2019 ............................................................................. 23

Figure 27a. Age and Sex Standardized, Total OME per Day per 1,000 Population, by Pharmacy Local Aggregated Geographies, 2019 ............................................................................... 24

Figure 27b. Age and Sex Standardized, Total OME per Day per 1,000 Population, by Pharmacy Local Aggregated Geographies, 2019 ............................................................................... 26

Figure 28a. Age and Sex Standardized, Opioid Patients per 1,000 Population, by Pharmacy Local Aggregated Geographies, 2019 ................................................................................ 28

Figure 28b. Age and Sex Standardized, Opioid Patients per 1,000 Population, by Pharmacy Local Aggregated Geographies, 2019 ................................................................................ 30

Figure 29a. Age and Sex Standardized, Opioid Patients Who Received 90 OME or Greater per Day per 1,000 Population, by Pharmacy Local Aggregated Geographies, 2019 .......................... 32

Figure 29b. Age and Sex Standardized, Opioid Patients Who Received 90 OME or Greater per Day per 1,000 Population, by Pharmacy Local Aggregated Geographies, 2019 ......................... 34

Figure 30a. Age and Sex Standardized, Total DDDs per 1,000 Population, by Pharmacy Local Aggregated Geographies, 2019 ............................................................................... 36

Figure 30b. Age and Sex Standardized, Total DDDs per 1,000 Population, by Pharmacy Local Aggregated Geographies, 2019 ............................................................................... 38

Figure 31a. Age and Sex Standardized, Benzodiazepine Patients per 1,000 Population, by Pharmacy Local Aggregated Geographies, 2019 ................................................................................ 40

Figure 31b. Age and Sex Standardized, Benzodiazepine Patients per 1,000 Population, by Pharmacy Local Aggregated Geographies, 2019 ................................................................................ 42

Figure 32a. Age and Sex Standardized, Benzodiazepine Patients Who Received 2 DDDs or Greater per 1,000 population, by Pharmacy Local Aggregated Geographies, 2019 .............................. 44

Figure 32b. Age and Sex Standardized, Benzodiazepine Patients Who Received 2 DDDs or Greater per 1,000 population, by Pharmacy Local Aggregated Geographies, 2019 ............................... 46

Figure 33a. Benzodiazepine Patients 65 Years and Older per 1,000 Elderly Population, by Pharmacy Local Aggregated Geographies, 2019 ................................................................................ 48

Figure 33b. Benzodiazepine Patients 65 Years and Older per 1,000 Elderly Population, by Pharmacy Local Aggregated Geographies, 2019 ................................................................................ 50

Figure 34a. Total DDDs in Benzodiazepine Patients 65 Years and Older per 1,000 Elderly Population, by Pharmacy Local Aggregate Geographies, 2019 ................................................................................ 52

Figure 34b. Total DDDs in Benzodiazepine Patients 65 Years and Older per 1,000 Elderly Population, by Pharmacy Local Aggregate Geographies, 2019 ................................................................................ 54

Figure 35a. Concurrent Benzodiazepine and Opioid Patients per 1,000 population, by Pharmacy Local Aggregated Geographies, 2019 ................................................................................ 56

Figure 35b. Concurrent Benzodiazepine and Opioid Patients per 1,000 population, by Pharmacy Local Aggregated Geographies, 2019 ................................................................................ 58

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